# NTSB WPR21LA329: Cessna 150D, N4375U, Chino, CA, August 25, 2021 - Type: NTSB accident investigation - Classification: Accident · Minor injuries · Class 3 · Limited · Final report - Date: August 25, 2021, 09:45 local (16:45 UTC) - Place: Chino, CA - Coordinates: 33.994387, -117.58998 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=33.9944&lon=-117.5900&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Defining event: [Enroute: Fuel related](https://openairdocs.org/ntsb-events/190) - Highest injury: Minor injuries - Injuries: 1 minor - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Western Pacific Region - Parties: Federal Aviation Administration - SAIBs cited in the narratives: [SAIB CE-09-35](https://openairdocs.org/saib/CE-09-35) (OpenAirDocs) - NTSB case key (mKey): 103761 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR21LA329 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103761/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=103761 - Page: https://openairdocs.org/ntsb/WPR21LA329 ## Probable cause The pilot’s delayed use of carburetor heat, which resulted in a loss of engine power due to carburetor icing. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Temp/humidity/pressure: conducive to carburetor icing](https://openairdocs.org/ntsb-findings/03031030): Environmental issues › Conditions/weather/phenomena · Contributed to outcome (probable cause); cases with it: [Cessna 150D, 1 case](https://openairdocs.org/ntsb-findings/03031030/cases.md?model=2071810), [All aircraft, 435 cases](https://openairdocs.org/ntsb-findings/03031030/cases.md) - [Action: delayed action](https://openairdocs.org/ntsb-findings/02041025): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Cessna 150D, 1 case](https://openairdocs.org/ntsb-findings/02041025/cases.md?model=2071810), [All aircraft, 894 cases](https://openairdocs.org/ntsb-findings/02041025/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Enroute: Fuel related](https://openairdocs.org/ntsb-events/190) (defining event); cases with it: [Cessna 150D, 2 cases](https://openairdocs.org/ntsb-events/190/sequence.md?model=2071810), [All aircraft, 361 cases](https://openairdocs.org/ntsb-events/190/sequence.md) ## Analysis The pilot flew in the local area for about 2 hours 45 minutes and then began to return to the departure airport. While the airplane was descending to 2,500 ft mean sea level, the engine surged, prompting the pilot to use carburetor heat. After a brief period of normal engine operation, the engine surging resumed, resulting in a partial power loss as the airplane approached the airport. Despite the pilot’s attempts to troubleshoot the issue, the airplane was unable to maintain altitude. The pilot performed an off-airport landing, during which the airplane collided with a fence. During the recovery of the airplane, about 3.5 to 4 gallons of fuel from the left wing and about 0.5 gallons of fuel from the right wing were drained, and both the carburetor bowl and gascolator contained fuel. The fuel tanks in the wing were intact, but fuel was dripping from the left fuel vent due to the angle at which the airplane came to rest (left wing down). Because fuel was dripping from the vent, the investigation could not determine if the airplane had a sufficient amount of fuel aboard at the time of the engine failure; the amount of fuel found in the tanks did not represent the amount of fuel aboard before impact. The Federal Aviation Administration (FAA) Carburetor Icing Probability Chart revealed that the outside air temperature and dew point temperature were within the "serious icing at glide power" portion of the chart, and the pilot reported haze in the area. An FAA Special Airworthiness Information Bulletin emphasized the risk of carburetor icing, even in above-freezing conditions with visible moisture, due to fuel vaporization and air expansion. Thus, it is likely that carburetor icing during the accident flight resulted in the loss of engine power, which might have been mitigated if the pilot had applied carburetor heat earlier in the descent. ## Factual narrative On August 25, 2021 about 0945 Pacific daylight time, a Cessna 150D, N4375U, was substantially damaged when it was involved in an accident near Ontario, California. The pilot sustained minor injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot stated that, before departure, she added 16 gallons of fuel to the fuel tank, which brought the total fuel aboard to 28 gallons. The pilot maneuvered in the local area for about 2 hours 45 minutes before returning to the airport. During the descent to 2,500 ft mean sea level (msl), the engine began to surge; in response, the pilot added carburetor heat. The engine sounded normal for about 3 to 4 minutes and then began to surge again. As the airplane approached the airport, the pilot noticed that a partial loss of engine power had occurred, and that the engine was running between 1,000 and 1,200 rpm, equivalent to a near-idle setting. The pilot attempted to troubleshoot the partial loss of power by verifying that the mixture was rich, the fuel selector was positioned to “BOTH,” and the magnetos were both selected. The pilot further stated that, despite these attempts, the airplane could not maintain level altitude, so she selected an area for an off-airport landing. About 20 seconds before touchdown, the engine lost total power, and the airplane collided with a fence, causing damage to the airplane wings. The pilot noted that, after the accident, fuel was draining from the airplane, and moisture (haze) was visible. Postaccident examination at the accident site found that the fuel tanks were intact, and only a small drip from the left fuel vent was observed. The airplane owner stated that he recovered the airplane and that about 3.5 to 4 gallons of fuel from the left wing and about 0.5 gallons from the right wing were drained. The owner added that both the carburetor bowl and gascolator contained fuel. A representative from Cessna Aircraft stated that the airplane was equipped with long range fuel tanks that held a total of 38 gallons of fuel. The representative estimated that the airplane had a range of 800 miles (or 7.1 hours) at 5,000 ft msl, with the engine at 2,500 rpm, and at a cruise speed of 113 mph. The airplane was equipped with an on/off fuel selector valve, and the two fuel tanks were interconnected before the valve. A check valve in the left fuel tank vent line was designed to prevent fuel from leaking out, but the valve contained a small (0.04 inch) hole so that pressure in a full tank could bleed out. The Cessna representative stated that this hole would allow a small drip of fuel to leak out of the tank when the airplane was in a left wing low position. The amount of fuel that leaked out would be based on the amount of fuel that was in the tank (head pressure) and the length of time that the airplane was in that position. Fuel could escape from the system if damage had occurred forward of the fuel valve. The Cessna representativeestimated that, on the basis of the accident flight track, the airplane should have had more than 10 gallons of fuel when the engine failure occurred. In a postaccident statement, the pilot indicated that, given the haze outside, she should have applied carburetor heat as soon as she began descending the airplane. The pilot further stated that she should have had a greater reserve of fuel and had planned for a 20% discrepancy in the airplane’s fuel performance numbers. The meteorological aerodrome report for Chino, California, that was issued at 0953 stated that the temperature was 79°F and the dew point was 61°F. The temperatures were applied to the FAA Carburetor Icing Probability Chart, which revealed that both recorded temperatures were within the "serious icing at glide power" portion of the chart. The FAA published Special Airworthiness Information Bulletin (SAIB) CE-09-35 in June 2009, which discussed carburetor ice prevention. The SAIB noted that carburetor icing does not only occur in freezing conditions; it can occur at temperatures well above freezing when visible moisture or high humidity is present. Vaporization of fuel combined with the expansion of air as it flows through the carburetor (the Venturi effect) causes sudden cooling, and a significant amount of ice can build up within a fraction of a second. ## Aircraft - Registration: [N4375U](https://openairdocs.org/deregistered/N4375U-2023-02-04), registration cancelled 2023-02-04, S/N 15060375, built 1964 (OpenAirDocs) - Reported make and model: CESSNA 150D - Registry model: [Cessna 150D](https://openairdocs.org/model/cessna-150d) (registry code 2071810) (OpenAirDocs) - Registry engine: [Continental 0-200 series](https://openairdocs.org/engine/continental-0-200-series) (registry code 17020, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 15060375 - Year built: 1964 - Airframe hours: 4878 - Engines: Continental O-200 100 hp reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Annual, October 2, 2020, 67.95 hours before - Departed: KCNO, Chino, CA - Airport: CNO, Chino - Equipment: Electronic flight bag or handheld device, ADS-B, Stall warning system ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 25; injuries: minor; commercial, flight instructor; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 1, without waivers/limitations; last flight review June 10, 2021; seat: left; restraint: lap only; flight hours: 735 total, 111 in this make and model, 535 as pilot in command, 122 in the last 90 days, 36 in the last 30 days, 1 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: calm - Visibility: 5 statute miles - Lowest ceiling: none - Temperature: 79 °F, dew point 61 °F - Altimeter: 29.98 inHg - Observed at: KCNO, 3 nm away - METAR: SPECI 00000KT 5SM HZ FEW200 26/16 A2998 ## FAA reports on this event (1) The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs). - [Accident 20210825014759A](https://openairdocs.org/incident/20210825014759A), Aug 25, 2021: Cessna 150D, Chino, CA, Substantial damage. The flight departed kcno on 08/25/2021 @0629 and flew for approximately 3HR 26 mins. The PIC flew to apple valley for an aircraft test flight, but did not… ## Docket (3 files) The files NTSB released with the investigation on September 20, 2023, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=103761. 2.2 MB in all. - Pilot/operator aircraft accident report, NTSB form 6120.1 (item 1, PDF, 7 pages, 1.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15966049&FileExtension=pdf&FileName=Z%20-%20Attachment%2001%20-%206120_Redacted-Rel.pdf - Record of conversations (item 2, PDF, 2 pages, 116 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15965978&FileExtension=pdf&FileName=Z%20-%20Attachment%2003%20-%20Record%20of%20Conversation-Rel.pdf - Pictures and graphs (item 3, PDF, 2 pages, 346 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15965187&FileExtension=pdf&FileName=Z%20-%20Attachment%2004%20-%20Graphs-Rel.pdf From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.